208.146. 1. The program established under this section shall be known as the "Ticket
to Work Health Assurance Program". Subject to appropriations and in accordance with the
federal Ticket to Work and Work Incentives Improvement Act of 1999 (TWWIIA), Public Law
106-170, the medical assistance provided for in section 208.151 may be paid for a person who
is employed and who:

(1) Except for earnings, meets the definition of disabled under the Supplemental Security
Income Program or meets the definition of an employed individual with a medically improved
disability under TWWIIA;

(2) Has earned income, as defined in subsection 2 of this section;

(3) Meets the asset limits in subsection 3 of this section;

(4) Has net income, as defined in subsection 3 of this section, that does not exceed the
limit for permanent and totally disabled individuals to receive nonspenddown MO HealthNet
under subdivision (24) of subsection 1 of section 208.151; and

(5) Has a gross income of two hundred fifty percent or less of the federal poverty level,
excluding any earned income of the worker with a disability between two hundred fifty and three
hundred percent of the federal poverty level. For purposes of this subdivision, "gross income"
includes all income of the person and the person's spouse that would be considered in
determining MO HealthNet eligibility for permanent and totally disabled individuals under
subdivision (24) of subsection 1 of section 208.151. Individuals with gross incomes in excess
of one hundred percent of the federal poverty level shall pay a premium for participation in
accordance with subsection 4 of this section.

2. For income to be considered earned income for purposes of this section, the
department of social services shall document that Medicare and Social Security taxes are
withheld from such income. Self-employed persons shall provide proof of payment of Medicare
and Social Security taxes for income to be considered earned.

3. (1) For purposes of determining eligibility under this section, the available asset limit
and the definition of available assets shall be the same as those used to determine MO HealthNet
eligibility for permanent and totally disabled individuals under subdivision (24) of subsection
1 of section 208.151 except for:

(a) Medical savings accounts limited to deposits of earned income and earnings on such
income while a participant in the program created under this section with a value not to exceed
five thousand dollars per year; and

(b) Independent living accounts limited to deposits of earned income and earnings on
such income while a participant in the program created under this section with a value not to
exceed five thousand dollars per year. For purposes of this section, an "independent living
account" means an account established and maintained to provide savings for transportation,
housing, home modification, and personal care services and assistive devices associated with
such person's disability.

(2) To determine net income, the following shall be disregarded:

(a) All earned income of the disabled worker;

(b) The first sixty-five dollars and one-half of the remaining earned income of a
nondisabled spouse's earned income;

(c) A twenty dollar standard deduction;

(d) Health insurance premiums;

(e) A seventy-five dollar a month standard deduction for the disabled worker's dental and
optical insurance when the total dental and optical insurance premiums are less than seventy-five
dollars;

(f) All Supplemental Security Income payments, and the first fifty dollars of SSDI
payments;

4. Any person whose gross income exceeds one hundred percent of the federal poverty
level shall pay a premium for participation in the medical assistance provided in this section.
Such premium shall be:

(1) For a person whose gross income is more than one hundred percent but less than one
hundred fifty percent of the federal poverty level, four percent of income at one hundred percent
of the federal poverty level;

(2) For a person whose gross income equals or exceeds one hundred fifty percent but is
less than two hundred percent of the federal poverty level, four percent of income at one hundred
fifty percent of the federal poverty level;

(3) For a person whose gross income equals or exceeds two hundred percent but less
than two hundred fifty percent of the federal poverty level, five percent of income at two hundred
percent of the federal poverty level;

(4) For a person whose gross income equals or exceeds two hundred fifty percent up to
and including three hundred percent of the federal poverty level, six percent of income at two
hundred fifty percent of the federal poverty level.

5. Recipients of services through this program shall report any change in income or
household size within ten days of the occurrence of such change. An increase in premiums
resulting from a reported change in income or household size shall be effective with the next
premium invoice that is mailed to a person after due process requirements have been met. A
decrease in premiums shall be effective the first day of the month immediately following the
month in which the change is reported.

6. If an eligible person's employer offers employer-sponsored health insurance and the
department of social services determines that it is more cost effective, such person shall
participate in the employer-sponsored insurance. The department shall pay such person's portion
of the premiums, co-payments, and any other costs associated with participation in the
employer-sponsored health insurance.

7. The provisions of this section shall expire [six years after August 28, 2007]July 1,
2014.

208.151. 1. Medical assistance on behalf of needy persons shall be known as "MO
HealthNet". For the purpose of paying MO HealthNet benefits and to comply with Title XIX,
Public Law 89-97, 1965 amendments to the federal Social Security Act (42 U.S.C. Section 301,
et seq.) as amended, the following needy persons shall be eligible to receive MO HealthNet
benefits to the extent and in the manner hereinafter provided, unless otherwise provided in
subsection 2 of this section:

(1) All participants receiving state supplemental payments for the aged, blind and
disabled;

(2) All participants receiving aid to families with dependent children benefits, including
all persons under nineteen years of age who would be classified as dependent children except for
the requirements of subdivision (1) of subsection 1 of section 208.040. Participants eligible
under this subdivision who are participating in drug court, as defined in section 478.001, shall
have their eligibility automatically extended sixty days from the time their dependent child is
removed from the custody of the participant, subject to approval of the Centers for Medicare and
Medicaid Services;

(3) All participants receiving blind pension benefits;

(4) All persons who would be determined to be eligible for old age assistance benefits,
permanent and total disability benefits, or aid to the blind benefits under the eligibility standards
in effect December 31, 1973, or less restrictive standards as established by rule of the family
support division, who are sixty-five years of age or over and are patients in state institutions for
mental diseases or tuberculosis;

(5) All persons under the age of twenty-one years who would be eligible for aid to
families with dependent children except for the requirements of subdivision (2) of subsection 1
of section 208.040, and who are residing in an intermediate care facility, or receiving active
treatment as inpatients in psychiatric facilities or programs, as defined in 42 U.S.C. 1396d, as
amended;

(6) All persons under the age of twenty-one years who would be eligible for aid to
families with dependent children benefits except for the requirement of deprivation of parental
support as provided for in subdivision (2) of subsection 1 of section 208.040;

(7) All persons eligible to receive nursing care benefits;

(8) All participants receiving family foster home or nonprofit private child-care
institution care, subsidized adoption benefits and parental school care wherein state funds are
used as partial or full payment for such care;

(9) All persons who were participants receiving old age assistance benefits, aid to the
permanently and totally disabled, or aid to the blind benefits on December 31, 1973, and who
continue to meet the eligibility requirements, except income, for these assistance categories, but
who are no longer receiving such benefits because of the implementation of Title XVI of the
federal Social Security Act, as amended;

(10) Pregnant women who meet the requirements for aid to families with dependent
children, except for the existence of a dependent child in the home;

(11) Pregnant women who meet the requirements for aid to families with dependent
children, except for the existence of a dependent child who is deprived of parental support as
provided for in subdivision (2) of subsection 1 of section 208.040;

(12) Pregnant women or infants under one year of age, or both, whose family income
does not exceed an income eligibility standard equal to one hundred eighty-five percent of the
federal poverty level as established and amended by the federal Department of Health and
Human Services, or its successor agency;

(13) Children who have attained one year of age but have not attained six years of age
who are eligible for medical assistance under 6401 of P.L. 101-239 (Omnibus Budget
Reconciliation Act of 1989). The family support division shall use an income eligibility standard
equal to one hundred thirty-three percent of the federal poverty level established by the
Department of Health and Human Services, or its successor agency;

(14) Children who have attained six years of age but have not attained nineteen years of
age. For children who have attained six years of age but have not attained nineteen years of age,
the family support division shall use an income assessment methodology which provides for
eligibility when family income is equal to or less than equal to one hundred percent of the federal
poverty level established by the Department of Health and Human Services, or its successor
agency. As necessary to provide MO HealthNet coverage under this subdivision, the department
of social services may revise the state MO HealthNet plan to extend coverage under 42 U.S.C.
1396a (a)(10)(A)(i)(III) to children who have attained six years of age but have not attained
nineteen years of age as permitted by paragraph (2) of subsection (n) of 42 U.S.C. 1396d using
a more liberal income assessment methodology as authorized by paragraph (2) of subsection (r)
of 42 U.S.C. 1396a;

(15) The family support division shall not establish a resource eligibility standard in
assessing eligibility for persons under subdivision (12), (13) or (14) of this subsection. The MO
HealthNet division shall define the amount and scope of benefits which are available to
individuals eligible under each of the subdivisions (12), (13), and (14) of this subsection, in
accordance with the requirements of federal law and regulations promulgated thereunder;

(16) Notwithstanding any other provisions of law to the contrary, ambulatory prenatal
care shall be made available to pregnant women during a period of presumptive eligibility
pursuant to 42 U.S.C. Section 1396r-1, as amended;

(17) A child born to a woman eligible for and receiving MO HealthNet benefits under
this section on the date of the child's birth shall be deemed to have applied for MO HealthNet
benefits and to have been found eligible for such assistance under such plan on the date of such
birth and to remain eligible for such assistance for a period of time determined in accordance
with applicable federal and state law and regulations so long as the child is a member of the
woman's household and either the woman remains eligible for such assistance or for children
born on or after January 1, 1991, the woman would remain eligible for such assistance if she
were still pregnant. Upon notification of such child's birth, the family support division shall
assign a MO HealthNet eligibility identification number to the child so that claims may be
submitted and paid under such child's identification number;

(18) Pregnant women and children eligible for MO HealthNet benefits pursuant to
subdivision (12), (13) or (14) of this subsection shall not as a condition of eligibility for MO
HealthNet benefits be required to apply for aid to families with dependent children. The family
support division shall utilize an application for eligibility for such persons which eliminates
information requirements other than those necessary to apply for MO HealthNet benefits. The
division shall provide such application forms to applicants whose preliminary income
information indicates that they are ineligible for aid to families with dependent children.
Applicants for MO HealthNet benefits under subdivision (12), (13) or (14) of this subsection
shall be informed of the aid to families with dependent children program and that they are
entitled to apply for such benefits. Any forms utilized by the family support division for
assessing eligibility under this chapter shall be as simple as practicable;

(19) Subject to appropriations necessary to recruit and train such staff, the family support
division shall provide one or more full-time, permanent eligibility specialists to process
applications for MO HealthNet benefits at the site of a health care provider, if the health care
provider requests the placement of such eligibility specialists and reimburses the division for the
expenses including but not limited to salaries, benefits, travel, training, telephone, supplies, and
equipment of such eligibility specialists. The division may provide a health care provider with
a part-time or temporary eligibility specialist at the site of a health care provider if the health care
provider requests the placement of such an eligibility specialist and reimburses the division for
the expenses, including but not limited to the salary, benefits, travel, training, telephone,
supplies, and equipment, of such an eligibility specialist. The division may seek to employ such
eligibility specialists who are otherwise qualified for such positions and who are current or
former welfare participants. The division may consider training such current or former welfare
participants as eligibility specialists for this program;

(20) Pregnant women who are eligible for, have applied for and have received MO
HealthNet benefits under subdivision (2), (10), (11) or (12) of this subsection shall continue to
be considered eligible for all pregnancy-related and postpartum MO HealthNet benefits provided
under section 208.152 until the end of the sixty-day period beginning on the last day of their
pregnancy;

(21) Case management services for pregnant women and young children at risk shall be
a covered service. To the greatest extent possible, and in compliance with federal law and
regulations, the department of health and senior services shall provide case management services
to pregnant women by contract or agreement with the department of social services through local
health departments organized under the provisions of chapter 192 or chapter 205 or a city health
department operated under a city charter or a combined city-county health department or other
department of health and senior services designees. To the greatest extent possible the
department of social services and the department of health and senior services shall mutually
coordinate all services for pregnant women and children with the crippled children's program,
the prevention of intellectual disability and developmental disability program and the prenatal
care program administered by the department of health and senior services. The department of
social services shall by regulation establish the methodology for reimbursement for case
management services provided by the department of health and senior services. For purposes
of this section, the term "case management" shall mean those activities of local public health
personnel to identify prospective MO HealthNet-eligible high-risk mothers and enroll them in
the state's MO HealthNet program, refer them to local physicians or local health departments
who provide prenatal care under physician protocol and who participate in the MO HealthNet
program for prenatal care and to ensure that said high-risk mothers receive support from all
private and public programs for which they are eligible and shall not include involvement in any
MO HealthNet prepaid, case-managed programs;

(22) By January 1, 1988, the department of social services and the department of health
and senior services shall study all significant aspects of presumptive eligibility for pregnant
women and submit a joint report on the subject, including projected costs and the time needed
for implementation, to the general assembly. The department of social services, at the direction
of the general assembly, may implement presumptive eligibility by regulation promulgated
pursuant to chapter 207;

(23) All participants who would be eligible for aid to families with dependent children
benefits except for the requirements of paragraph (d) of subdivision (1) of section 208.150;

(24) (a) All persons who would be determined to be eligible for old age assistance
benefits under the eligibility standards in effect December 31, 1973, as authorized by 42 U.S.C.
Section 1396a(f), or less restrictive methodologies as contained in the MO HealthNet state plan
as of January 1, 2005; except that, on or after July 1, 2005, less restrictive income
methodologies, as authorized in 42 U.S.C. Section 1396a(r)(2), may be used to change the
income limit if authorized by annual appropriation;

(b) All persons who would be determined to be eligible for aid to the blind benefits
under the eligibility standards in effect December 31, 1973, as authorized by 42 U.S.C. Section
1396a(f), or less restrictive methodologies as contained in the MO HealthNet state plan as of
January 1, 2005, except that less restrictive income methodologies, as authorized in 42 U.S.C.
Section 1396a(r)(2), shall be used to raise the income limit to one hundred percent of the federal
poverty level;

(c) All persons who would be determined to be eligible for permanent and total disability
benefits under the eligibility standards in effect December 31, 1973, as authorized by 42 U.S.C.
1396a(f); or less restrictive methodologies as contained in the MO HealthNet state plan as of
January 1, 2005; except that, on or after July 1, 2005, less restrictive income methodologies, as
authorized in 42 U.S.C. Section 1396a(r)(2), may be used to change the income limit if
authorized by annual appropriations. Eligibility standards for permanent and total disability
benefits shall not be limited by age;

(25) Persons who have been diagnosed with breast or cervical cancer and who are
eligible for coverage pursuant to 42 U.S.C. 1396a (a)(10)(A)(ii)(XVIII). Such persons shall be
eligible during a period of presumptive eligibility in accordance with 42 U.S.C. 1396r-1;

(26) Effective August 28, 2013, persons who are [independent foster care adolescents,
as defined in 42 U.S.C. Section 1396d, or who are within reasonable categories of such
adolescents who are under twenty-one years of age as specified by the state, are eligible for
coverage under 42 U.S.C. Section 1396a (a)(10)(A)(ii)(XVII) without regard to income or assets]in foster care under the responsibility of the state of Missouri on the date such persons
attain the age of eighteen years, or at any time during the thirty-day period preceding their
eighteenth birthday, without regard to income or assets, if such persons:

(a) Are under twenty-six years of age;

(b) Are not eligible for coverage under another mandatory coverage group; and

(1) Persons eligible under subdivisions (3) and (25) of subsection 1 of this section
shall no longer be eligible for MO HealthNet benefits as provided in this section, except for
those persons eligible under subdivision (25) who do not have access to employer-sponsored
health insurance coverage or subsidized insurance coverage through an exchange at any
point after diagnosis, whose income is between one hundred percent and two hundred
percent of the federal poverty level;

(2) Pregnant women who are eligible under subdivision (12) of subsection 1 of this
section, with income between one hundred thirty-three and one hundred eighty-five
percent of the federal poverty level shall be eligible for MO HealthNet in the form of a
premium subsidy as established by rule of the department in order for them to enroll in
a plan offered by a health care exchange, whether federally facilitated, state based, or
operated on a partnership basis. The pregnant women shall be directed to choose an
exchange plan and shall be eligible for a premium subsidy equal to the amount of the
percentage of income required for premium payments or coinsurance to the pregnant
women by federal rule;

(3) Beginning October 1, 2019, infants under one year of age who are eligible under
subdivision (12) of subsection 1 of this section shall be limited to those infants whose family
income does not exceed one hundred eighty-five percent of the federal poverty level as
established and amended by the federal Department of Health and Human Services or its
successor agency. Infants under one year of age born to women who were covered under
subdivision (2) of this subsection with family income between one hundred thirty-three and
one hundred eighty-five percent of the federal poverty level shall only be eligible if, in
addition to the other requirements, his or her parents do not have access to health
insurance coverage for the child through a health insurance plan in a health care exchange,
whether federally facilitated, state based, or operated on a partnership basis, and the
parents are not eligible for a premium subsidy for the child or family through such
exchange because the parents have been determined to have access to affordable health
insurance as defined by the exchange;

(4) The changes in eligibility under subdivisions (1) to (3) of this subsection shall
not take place unless and until:

(a) There are health insurance premium tax credits under Section 36B of the
Internal Revenue Code of 1986, as amended, available to persons through the purchase of
a health insurance plan in a health care exchange, whether federally facilitated, state
based, or operated on a partnership basis. The director of the department of revenue shall
certify to the director of the department that health insurance premium tax credits are
available, and the director of the department shall notify the revisor of statutes;

(b) Eligibility of persons set out in subsection 3 of section 208.995 has been
approved by the federal Department of Health and Human Services, has been implemented
by the department, and notice of implementation has been provided to the revisor of
statutes; and

(c) The federal Department of Health and Human Services grants any necessary
waivers and state plan amendments to implement this subsection, federal funding is
received for the premium subsidies to be paid, and notice has been provided to the revisor
of statutes.

3. Rules and regulations to implement this section shall be promulgated in accordance
with [section 431.064 and] chapter 536. Any rule or portion of a rule, as that term is defined in
section 536.010, that is created under the authority delegated in this section shall become
effective only if it complies with and is subject to all of the provisions of chapter 536 and, if
applicable, section 536.028. This section and chapter 536 are nonseverable and if any of the
powers vested with the general assembly pursuant to chapter 536 to review, to delay the effective
date or to disapprove and annul a rule are subsequently held unconstitutional, then the grant of
rulemaking authority and any rule proposed or adopted after August 28, 2002, shall be invalid
and void.

[3.]4. After December 31, 1973, and before April 1, 1990, any family eligible for
assistance pursuant to 42 U.S.C. 601, et seq., as amended, in at least three of the last six months
immediately preceding the month in which such family became ineligible for such assistance
because of increased income from employment shall, while a member of such family is
employed, remain eligible for MO HealthNet benefits for four calendar months following the
month in which such family would otherwise be determined to be ineligible for such assistance
because of income and resource limitation. After April 1, 1990, any family receiving aid
pursuant to 42 U.S.C. 601, et seq., as amended, in at least three of the six months immediately
preceding the month in which such family becomes ineligible for such aid, because of hours of
employment or income from employment of the caretaker relative, shall remain eligible for MO
HealthNet benefits for six calendar months following the month of such ineligibility as long as
such family includes a child as provided in 42 U.S.C. 1396r-6. Each family which has received
such medical assistance during the entire six-month period described in this section and which
meets reporting requirements and income tests established by the division and continues to
include a child as provided in 42 U.S.C. 1396r-6 shall receive MO HealthNet benefits without
fee for an additional six months. The MO HealthNet division may provide by rule and as
authorized by annual appropriation the scope of MO HealthNet coverage to be granted to such
families.

[4.]5. When any individual has been determined to be eligible for MO HealthNet
benefits, such medical assistance will be made available to him or her for care and services
furnished in or after the third month before the month in which he made application for such
assistance if such individual was, or upon application would have been, eligible for such
assistance at the time such care and services were furnished; provided, further, that such medical
expenses remain unpaid.

[5.]6. The department of social services may apply to the federal Department of Health
and Human Services for a MO HealthNet waiver amendment to the Section 1115 demonstration
waiver or for any additional MO HealthNet waivers necessary not to exceed one million dollars
in additional costs to the state, unless subject to appropriation or directed by statute, but in no
event shall such waiver applications or amendments seek to waive the services of a rural health
clinic or a federally qualified health center as defined in 42 U.S.C. 1396d(l)(1) and (2) or the
payment requirements for such clinics and centers as provided in 42 U.S.C. 1396a(a)(15) and
1396a(bb) unless such waiver application is approved by the oversight committee created in
section 208.955. A request for such a waiver so submitted shall only become effective by
executive order not sooner than ninety days after the final adjournment of the session of the
general assembly to which it is submitted, unless it is disapproved within sixty days of its
submission to a regular session by a senate or house resolution adopted by a majority vote of the
respective elected members thereof, unless the request for such a waiver is made subject to
appropriation or directed by statute.

[6.]7. Notwithstanding any other provision of law to the contrary, in any given fiscal
year, any persons made eligible for MO HealthNet benefits under subdivisions (1) to (22) of
subsection 1 of this section shall only be eligible if annual appropriations are made for such
eligibility. This subsection shall not apply to classes of individuals listed in 42 U.S.C. Section
1396a(a)(10)(A)(i).

8. The department shall notify any potential exchange-eligible participant who may
be eligible for services due to spenddown that the participant may qualify for more cost-effective private insurance and premium tax credits under Section 36B of the Internal
Revenue Code of 1986, as amended, available through the purchase of a health insurance
plan in a health care exchange, whether federally facilitated, state based, or operated on
a partnership basis and the benefits that would be potentially covered under such
insurance.

208.186. 1. Any person participating in the MO HealthNet program who has pled
guilty to or been found guilty of a crime involving alcohol or a controlled substance or any
crime in which alcohol or substance abuse was, in the opinion of the court, a contributing
factor to the person’s commission of the crime shall be required to obtain an assessment
by a treatment provider approved by the department of mental health to determine the
need for services. Recommendations of the treatment provider may be used by the court
in sentencing.

2. Any person participating in the MO HealthNet program who is a parent of a
child subject to proceedings in juvenile court under subsection 1 or 2 of section 211.031,
whose misuse of controlled substances or alcohol is found to be a significant, contributing
factor to the reason the child was adjudicated, shall be required to obtain an assessment
by a treatment provider approved by the department of mental health to determine the
need for services. Recommendations of the treatment provider shall be included in the
child’s permanency plan. The court may order the parent or guardian to successfully
complete treatment before the child is reunified with the parent or guardian.

3. The MO HealthNet division shall certify a MO HealthNet participant’s
enrollment in MO HealthNet if requested by the court under this section. A letter signed
by the director of the MO HealthNet division or his or her designee or the family support
division certifying that the individual is a participant in the MO HealthNet program shall
be prima facie evidence of such participation and shall be admissible into evidence without
further foundation for that purpose. The letter may specify additional information such
as anticipated dates of coverage as may be deemed necessary by the department.

208.631. 1. Notwithstanding any other provision of law to the contrary, the MO
HealthNet division shall establish a program to pay for health care for uninsured children.
Coverage pursuant to sections 208.631 to 208.659 is subject to appropriation. The provisions
of sections 208.631 to 208.569, health care for uninsured children, shall be void and of no effect
if there are no funds of the United States appropriated by Congress to be provided to the state
on the basis of a state plan approved by the federal government under the federal Social Security
Act. If funds are appropriated by the United States Congress, the department of social services
is authorized to manage the state children's health insurance program (SCHIP) allotment in order
to ensure that the state receives maximum federal financial participation. Children in households
with incomes up to one hundred fifty percent of the federal poverty level may meet all Title XIX
program guidelines as required by the Centers for Medicare and Medicaid Services. Children
in households with incomes of one hundred fifty percent to three hundred percent of the federal
poverty level shall continue to be eligible as they were and receive services as they did on June
30, 2007, unless changed by the Missouri general assembly.

2. For the purposes of sections 208.631 to 208.659, "children" are persons up to nineteen
years of age. "Uninsured children" are persons up to nineteen years of age who are emancipated
and do not have access to affordable employer-subsidized health care insurance or other health
care coverage or persons whose parent or guardian have not had access to affordable
employer-subsidized health care insurance or other health care coverage for their children for six
months prior to application, are residents of the state of Missouri, and have parents or guardians
who meet the requirements in section 208.636. A child who is eligible for MO HealthNet
benefits as authorized in section 208.151 is not uninsured for the purposes of sections 208.631
to 208.659.

3. Beginning October 1, 2019, a child eligible under sections 208.631 to 208.658
shall only remain eligible if, in addition to the other requirements, his or her parents do not
have access to health insurance coverage for the child through their employment or
through a health insurance plan in a health care exchange, whether federally facilitated,
state based, or operated on a partnership basis because the parents are not eligible for a
premium subsidy for the child or family through such exchange. This subsection shall not
go into effect unless and until, for a six-month period preceding the additional
requirements, there are health insurance premium tax credits available for children and
family coverage under Section 36B of the Internal Revenue Code of 1986, as amended,
available to persons through the purchase of a health insurance plan in a health care
exchange, whether federally facilitated, state based, or operated on a partnership basis,
which have been in place for a six-month period.

4. The department shall inform participants six months prior to coverage being
discontinued under subsection 3 of this section as to the possibility of insurance coverage
through the purchase of a subsidized health insurance plan available through a health care
exchange.

208.659. 1. The MO HealthNet division shall revise the eligibility requirements for the
uninsured women's health program, as established in 13 CSR Section 70-4.090, to include
women who are at least eighteen years of age and with a net family income of at or below one
hundred eighty-five percent of the federal poverty level. In order to be eligible for such program,
the applicant shall not have assets in excess of two hundred and fifty thousand dollars, nor shall
the applicant have access to employer-sponsored health insurance. Such change in eligibility
requirements shall not result in any change in services provided under the program.

2. Beginning July 1, 2014, the provisions of this section shall no longer be in effect.
Such change in eligibility shall not take place unless and until:

(1) For a six-month period preceding the discontinuance of benefits under this
subsection there are health insurance premium tax credits available for children and
family coverage under Section 36B of the Internal Revenue Code of 1986, as amended,
available to persons through the purchase of a health insurance plan in a health care
exchange, whether federally facilitated, state based, or operated on a partnership basis,
which have been in place for a six-month period, and notice has been provided to the
revisor of statutes; and

(2) Eligibility of persons set out in subsection 3 of section 208.995 has received any
necessary approvals from the federal Department of Health and Human Services, has been
implemented by the department, and notice has been provided to the revisor of statutes.

3. The department shall inform participants six months prior to coverage being
discontinued under subsection 2 of this section as to the possibility of insurance coverage
through the purchase of a subsidized health insurance plan available through a health care
exchange.

208.661. 1. The department shall develop incentive programs, submit state plan
amendments and apply for necessary waivers to permit rural health clinics, federally-qualified health centers, or other primary care practices to co-locate on the property of
public elementary and secondary schools with fifty percent or more students who are
eligible for free or reduced price lunch.

2. No school-based health care clinic established under this section shall perform
or refer for abortion services, or provide or refer for contraceptive drugs or devices.

3. The consent of a parent or legal guardian shall be required before a minor may
receive health care services under this section.

4. The provisions of this section shall be null and void unless and until any waivers
necessary to the implementation of subsections 2 and 3 of this section are granted by the
federal government.

208.662. 1. There is hereby established within the department of social services the
“Show-Me Healthy Babies Program” as a separate children’s health insurance program
(CHIP) for any low-income, unborn child, neither of whose parents have access to
affordable health insurance coverage for the unborn child through his or her employment
or through a health insurance plan in a health care exchange, whether federally facilitated,
state based, or operated on a partnership basis. The program shall be established under
the authority of Title XXI of the federal Social Security Act, the State Children’s Health
Insurance Program, as amended, and 42 CFR 457.1.

2. For an unborn child to be enrolled in the show-me healthy babies program, his
or her mother shall not be eligible for coverage under Title XIX of the federal Social
Security Act, the Medicaid program, as it is administered by the state, and shall not have
access to affordable employer-subsidized health care insurance or other affordable health
care coverage that includes coverage for the unborn child including any health insurance
plan in a health care exchange, whether federally facilitated, state based, or operated on
a partnership basis.

3. Coverage for an unborn child enrolled in the show-me healthy babies program
shall include all prenatal care and pregnancy-related services that benefit the health of the
unborn child and that promote healthy labor, delivery, and birth, as determined by
regulations of the department. Coverage shall not include services that are solely for the
benefit of the pregnant mother, that are unrelated to maintaining or promoting a healthy
pregnancy, and that provide no benefit to the unborn child.

4. There shall be no waiting period before an unborn child may be enrolled in the
show-me healthy babies program. In accordance with the definition of child in 42 CFR
457.10, coverage shall include the period from conception to birth. The department shall
develop a presumptive eligibility procedure for enrolling an unborn child.

5. Coverage for the child shall continue for up to one year after birth, unless
otherwise prohibited by law or unless otherwise limited by the general assembly through
appropriations.

6. Pregnancy-related and postpartum coverage for the mother shall begin on the
day the pregnancy ends and extend through the last day of the month that includes the
sixtieth day after the pregnancy ends, unless otherwise prohibited by law or unless
otherwise limited by the general assembly through appropriations. Coverage for the
mother shall be limited to pregnancy-related and postpartum care.

7. Nothing in this section shall be construed to prohibit an unborn child from being
enrolled in the show-me healthy babies program at the same time his or her mother is
enrolled in MO HealthNet, the children's health insurance program (CHIP), Medicare, or
other governmental or government-subsidized health care program. The department shall
ensure that there is no duplication of payments for services for an unborn child enrolled
in the show-me healthy babies program that are payable under a governmental or
nongovernmental health care program for services to an eligible pregnant woman.

8. The department may provide coverage for an unborn child enrolled in the show-me healthy babies program through:

(1) Direct coverage whereby the state pays health care providers directly or by
contracting with a managed care organization or with a group or individual health
insurance provider;

(2) A premium assistance program whereby the state assists in payment of the
premiums, co-payments, coinsurance, or deductibles for a person who is eligible for health
coverage through an employer, former employer, labor union, credit union, church,
spouse, other organizations, other individuals, or through an individual health insurance
policy that includes coverage for the unborn child, when such person needs assistance in
paying such premiums, co-payments, coinsurance, or deductibles;

(3) A combination of direct coverage, such as when the unborn child is first
enrolled, and premium assistance, such as after the child is born; or

(4) Any other similar arrangement whereby there:

(a) Are lower program costs without sacrificing health care coverage for the
unborn child or the child up to one year after birth;

(b) Are greater covered services for the unborn child or the child up to one year
after birth;

(c) Is a similar cost for coverage of the participant and also will provide coverage
for siblings or other family members; or

(d) Will be an ability for the child to transition more easily to nongovernment or
less government-subsidized group or individual health insurance coverage after the child
is no longer enrolled in the show-me healthy babies program.

9. The department shall provide information about the show-me healthy babies
program to maternity homes as defined in section 135.600, pregnancy resource centers as
defined in section 135.630, and other similar agencies and programs in the state that assist
unborn children and their mothers. The department shall consider allowing such agencies
and programs to assist in the enrollment of unborn children in the program and in making
determinations about presumptive eligibility.

10. Within sixty days after the effective date of this section, the department shall
submit a state plan amendment or seek any necessary waivers from the federal Department
of Health and Human Services requesting approval for the show-me healthy babies
program.

11. At least annually, the department shall prepare and submit a report to the
governor, the speaker of the house of representatives, and the president pro tem of the
senate analyzing the cost savings and benefits, if any, to the state, counties, local
communities, school districts, law enforcement agencies, health care providers, employers,
other public and private entities, and persons by enrolling unborn children in the show-me
healthy babies program. The analysis of cost savings and benefits, if any, shall include but
not be limited to:

(1) The higher federal matching rate for having an unborn child enrolled in the
show-me healthy babies program versus the lower federal matching rate for a pregnant
woman being enrolled in MO HealthNet or other federal programs;

(2) The efficacy in providing services through managed care organizations, group
or individual health insurance providers or premium assistance, or through other
nontraditional arrangements of providing health care;

(3) The change in the proportion of unborn children who receive care in the first
trimester of pregnancy due to a lack of waiting periods, presumptive eligibility, or removal
of other barriers, and the attendant decrease in health problems and other problems for
unborn children and women throughout pregnancy; at labor, delivery, and birth; and
during infancy and childhood;

(4) The change in healthy behaviors by pregnant women, such as the cessation of
the use of tobacco, alcohol, illicit drugs, or other harmful practices, and the attendant
short-term and long-term decrease in birth defects; poor motor skills; vision, speech, and
hearing problems; breathing and respiratory problems; feeding and digestive problems;
and other physical, mental, educational, and behavioral problems; and

(5) The change in infant and maternal mortality, preterm births and low birth
weight babies and the attendant decrease in short-term and long-term medical and other
interventions.

12. The show-me healthy babies program shall not be deemed an entitlement
program, but instead shall be subject to a federal allotment or other federal appropriations
and matching state appropriations.

13. Nothing in this section shall be construed as obligating the state to continue the
show-me healthy babies program if the allotment or payments from the federal
government end or are not sufficient for the program to operate, or if the general assembly
does not appropriate funds for the program.

14. Nothing in this section shall be construed as expanding MO HealthNet or
fulfilling a mandate imposed by the federal government on the state.

2. Notwithstanding any other provisions of law to the contrary, to be eligible for
MO HealthNet coverage individuals shall meet the eligibility criteria set forth in 42 CFR
435, including but not limited to the requirements that:

(1) The individual is a resident of the state of Missouri;

(2) The individual has a valid Social Security number;

(3) The individual is a citizen of the United States or a qualified alien as described
in Section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act
of 1996, 8 U.S.C. Section 1641, who has provided satisfactory documentary evidence of
qualified alien status which has been verified with the Department of Homeland Security
under a declaration required by Section 1137(d) of the Personal Responsibility and Work
Opportunity Reconciliation Act of 1996 that the applicant or beneficiary is an alien in a
satisfactory immigration status; and

3. Notwithstanding any other provisions of law to the contrary, effective January 1,
2014, the family support division shall conduct an annual redetermination of all MO
HealthNet participants' eligibility as provided in 42 CFR 435.916. The department may
contract with an administrative service organization to conduct the annual
redeterminations if it is cost effective.

4. The department, or family support division, shall conduct electronic searches to
redetermine eligibility on the basis of income, residency, citizenship, identity and other
criteria as described in 42 CFR 435.916 upon availability of federal, state, and
commercially available electronic data sources. The department, or family support
division, may enter into a contract with a vendor to perform the electronic search of
eligibility information not disclosed during the application process and obtain an
applicable case management system. The department shall retain final authority over
eligibility determinations made during the redetermination process.

5. Notwithstanding any other provisions of law to the contrary, applications for
MO HealthNet benefits shall be submitted in accordance with the requirements of 42 CFR
435.907 and other applicable federal law. The individual shall provide all required
information and documentation necessary to make an eligibility determination, resolve
discrepancies found during the redetermination process, or for a purpose directly
connected to the administration of the medical assistance program.

6. Notwithstanding any other provisions of law to the contrary, to be eligible for
MO HealthNet coverage under section 208.995, individuals shall meet the eligibility
requirements set forth in subsection 2 of this section and all other eligibility criteria set
forth in 42 CFR 435 and 457, including, but not limited to, the requirements that:

(1) The department of social services shall determine the individual's financial
eligibility based on projected annual household income and family size for the remainder
of the current calendar year;

(2) The department of social services shall determine household income for the
purpose of determining the modified adjusted gross income by including all available cash
support provided by the person claiming such individual as a dependent for tax purposes;

(3) The department of social services shall determine a pregnant woman's
household size by counting the pregnant woman plus the number of children she is
expected to deliver;

(4) CHIP-eligible children shall be uninsured, shall not have access to affordable
insurance, and their parent shall pay the required premium;

(5) An individual claiming eligibility as an uninsured woman shall be uninsured.

7. The MO HealthNet program shall not provide MO HealthNet coverage under
subsection 3 of section 208.995 to a parent or other caretaker relative living with a
dependent child unless the child is receiving benefits under the MO HealthNet program,
the Children's Health Insurance Program (CHIP) under 42 CFR Chapter IV, Subchapter
D, or otherwise is enrolled in minimum essential coverage as defined in 42 CFR 435.4.

8. (1) The provisions of the show-me transformation act shall be null and void
unless and until:

(a) There are health insurance premium tax credits under Section 36B of the
Internal Revenue Code of 1986, as amended, available to persons through the purchase of
a health insurance plan in a heath care exchange, whether federally facilitated, state based,
or operated on a partnership basis;

(b) Eligibility of persons set out in subsection 3 of section 208.995 has been
approved by the federal Department of Health and Human Services and has been
implemented by the department;

(c) The federal Department of Health and Human Services grants the required
waivers, state plan amendments, and enhanced federal funding rate for persons newly
eligible under subsection 3 of section 208.995 whereby the federal government agrees to
pay the percentages specified in Section 2001 of PL 111-148, as that section existed on
March 23, 2010. The provisions of subsections 3 to 8 of section 208.995 shall not be
implemented unless such waivers and enhanced federal funding rates are granted by the
federal government;

(2) If the federal funds at the disposal of the state shall at any time become less than
ninety percent of the funds necessary or are not appropriated to pay the percentages
specified in Section 2001 of Public Law 111-148, as that section existed on March 23, 2010,
the provisions of this act shall be null and void. If the director is notified that federal
funding will fall below ninety percent of the funds necessary, participants will be notified
as soon as practicable that the benefits they receive will terminate on the date that federal
funding falls below ninety percent.

(3) The provisions of subdivisions (1) and (2) of this subsection shall not apply to:
the MO HealthNet transformation task force under section 2; subdivision (26) of
subsection 1 of section 208.151; subsections 2, 3, 4, 5, and 6 of this section; and subdivision
(2) of subsection 2 of section 208.995.

9. As MO HealthNet or other expenditures are reduced or savings achieved
pursuant to the show-me transformation act, the portion of the state share of those
expenditures that is funded by provider taxes described in 42 CFR 433.56 shall be credited
or otherwise shall accrue to the depository account in which the proceeds of such a
provider tax are deposited.

208.995. 1. For purposes of sections 208.990 to 208.998, the following terms mean:

(1) "Caretaker relative", a relative of a dependent child by blood, adoption, or
marriage with whom the child is living, who assumes primary responsibility for the child's
care, which may, but is not required to, be indicated by claiming the child as a tax
dependent for federal income tax purposes, and who is one of the following:

(b) The spouse of such parent or relative, even after the marriage is terminated by
death or divorce;

(2) "Child" or "children", a person or persons who are under nineteen years of
age;

(3) "CHIP-eligible children", children who meet the eligibility standards for
Missouri's children's health insurance program as provided in sections 208.631 to 208.658,
including paying the premiums required under sections 208.631 to 208.658;

(4) "Department", the Missouri department of social services, or a division or unit
within the department as designated by the department's director;

(5) "MAGI", the individual's modified adjusted gross income as defined in Section
36B(d)(2) of the Internal Revenue Code of 1986, as amended, and:

(a) Any foreign earned income or housing costs;

(b) Tax-exempt interest received or accrued by the individual; and

(c) Tax-exempt Social Security income;

(6) "MAGI equivalent net income standard", an income eligibility threshold based
on modified adjusted gross income that is not less than the income eligibility levels that
were in effect prior to the enactment of Public Law 111-148 and Public Law 111-152;

(7) "Medically frail", individuals with:

(a) Serious emotional disturbances;

(b) Disabling mental disorders;

(c) Substance use disorders or chronic medical conditions who are at high risk for
significant medical and social costs;

(d) Serious and complex medical conditions, including children who are deemed
medically complex;

(e) Physical or mental disabilities that significantly impair the person’s ability to
perform one or more activities of daily living; or

(f) An adjudicated level of care of twenty-one points or greater as determined by
the screening process under 42 CFR 483.100 to 483.138, or deemed eligible for skilled
nursing facility placement, but who are not currently residing in a nursing facility.

2. (1) Effective January 1, 2014, notwithstanding any other provision of law to the
contrary, the following individuals shall be eligible for MO HealthNet coverage as provided
in this section:

(a) Individuals covered by MO HealthNet for families as provided in section
208.145;

(e) Children under one year of age as provided in subdivision (12) of subsection 1
of section 208.151;

(f) Children under six years of age as provided in subdivision (13) of subsection 1
of section 208.151;

(g) Children under nineteen years of age as provided in subdivision (14) of
subsection 1 of section 208.151;

(h) CHIP-eligible children; and

(i) Uninsured women as provided in section 208.659.

(2) Effective January 1, 2014, the department shall determine eligibility for
individuals eligible for MO HealthNet under subdivision (1) of this subsection based on the
following income eligibility standards, unless and until they are changed under subsection
2 of section 208.151:

(a) For individuals listed in paragraphs (a), (b) and (c) of subdivision (1) of this
subsection, the department shall apply the July 16, 1996, Aid to Families with Dependent
Children (AFDC) income standard as converted to the MAGI equivalent net income
standard;

(b) For individuals listed in paragraphs (f) and (g) of subdivision (1) of this
subsection, the department shall apply one hundred thirty-three percent of the federal
poverty level converted to the MAGI equivalent net income standard;

(c) For individuals listed in paragraph (h) of subdivision (1) of this subsection, the
department shall convert the income eligibility standard set forth in section 208.633 to the
MAGI equivalent net income standard;

(d) For individuals listed in paragraphs (d), (e) and (i) of subdivision (1) of this
subsection, the department shall apply one hundred eighty-five percent of the federal
poverty level converted to the MAGI equivalent net income standard;

(3) Individuals eligible for MO HealthNet under subdivision (1) of this subsection
shall receive all applicable benefits under section 208.152.

3. (1) Effective January 1, 2014, and subject to the receipt of appropriate waivers
and approval of state plan amendments, individuals who meet the following qualifications
shall be eligible for the alternative package of MO HealthNet benefits as set forth in
subsection 5 of this section, subject to the other requirements of this section:

(a) Are nineteen years of age or older and under sixty-five years of age;

(b) Are not pregnant;

(c) Are not entitled to or enrolled for Medicare benefits under Part A or B of Title
XVIII of the Social Security Act;

(d) Are not otherwise eligible for and enrolled in mandatory coverage under
Missouri's MO HealthNet program in accordance with 42 CFR 435, Subpart B; and

(e) Have household income that is at or below one hundred percent of the federal
poverty level for the applicable family size for the applicable year under the MAGI
equivalent net income standard.

(2) The department shall immediately seek any necessary waivers from the federal
Department of Health and Human Services to implement the provisions of this subsection.
The waivers shall:

(a) Promote healthy behavior and reasonable requirements that patients take
ownership of their health care by seeking early preventative care in appropriate settings,
including no co-payments for preventive care services;

(b) Require personal responsibility in the payment of health care by establishing
appropriate co-payments based on family income that shall discourage the use of
emergency room visits for non-emergent health situations and promote responsible use of
other health care services;

(c) Promote the adoption of healthier personal habits including limiting tobacco use
or behaviors that lead to obesity;

(d) Allow recipients to receive an annual cash incentive to promote responsible
behavior and encourage efficient use of health care services; and

(e) Allow health plans to offer a health savings account option.

(f) Include a request for an enhanced federal funding rate consistent with
subsection 10 of this section for newly eligible participants.

(3) If such waivers and enhanced federal funding rate are not granted by the
federal government, the provisions of this subsection shall be null and void.

4. Except for those individuals who meet the definition of medically frail,
individuals eligible for MO HealthNet benefits under subsection 3 of this section shall
receive only a package of alternative minimum benefits. The MO HealthNet division of the
department of social services shall promulgate regulations to be effective January 1, 2014,
that provide an alternative benefit package that complies with the requirements of federal
law and is subject to limitations as established in regulations of the MO HealthNet division.

5. Except for those individuals who meet the definition of medically frail,
individuals who qualify for coverage under subsections 2 and 3 of this section shall receive
covered services through health plans authorized by the department under section 208.998.

6. The department shall provide premium subsidy and other cost supports for
individuals eligible for MO HealthNet under subsections 2 and 3 of this section to enroll
in employer-provided health plans or other private health plans based on cost-effective
principles determined by the department.

7. Individuals eligible for MO HealthNet benefits under subsections 2 and 3 of this
section who meet the definition of medically frail shall receive all benefits they are eligible
to receive under sections 208.152, 208.900, 208.903, 208.909, and 208.930.

8. The department shall establish a screening process in conjunction with the
department of mental health and the department of health and senior services for
determining whether an individual is medically frail and shall enroll all eligible individuals
who meet the definition of medically frail and whose care management would benefit from
being assigned a health home in the health home program or other care coordination as
established by the department. Any eligible individual may opt out of the health home
program.

9. The department or appropriate divisions of the department shall promulgate
rules to implement the provisions of this section. Any rule or portion of a rule, as the term
is defined in section 536.010, that is created under the authority delegated in this section
shall become effective only if it complies with and is subject to all of the provisions of
chapter 536 and, if applicable, section 536.028. This section and chapter 536 are
nonseverable and if any of the powers vested with the general assembly pursuant to
chapter 536 to review, to delay the effective date or to disapprove and annul a rule are
subsequently held unconstitutional, then the grant of rulemaking authority and any rule
proposed or adopted after August 28, 2013, shall be invalid and void.

10. The department shall submit such state plan amendments and waivers to the
Centers for Medicare and Medicaid Services of the federal Department of Health and
Human Services as the department determines are necessary to implement the provisions
of this section. The department shall request of the federal government an enhanced
federal funding rate for persons newly eligible under subsection 3 of this section whereby
the federal government agrees to pay the percentages specified in Section 2001 of PL 111-148, as that section existed on March 23, 2010. The provisions of subsections 3 to 8 of this
section shall not be implemented unless such waivers and enhanced federal funding rates
are granted by the federal government.

11. If at any time the director receives notice that the federal funds at the disposal
of the state for payments of money benefits to or on behalf of any persons under subsection
3 of this section shall at any time become less than ninety percent of the funds necessary
or are not appropriated to pay the percentages specified in Section 2001 of Public Law
111-148, as that section existed on March 23, 2010, subsections 3 to 8 of this section shall
no longer be effective for the individuals whose benefits are no longer matchable at the
specified percentages. The date benefits cease shall be stated in a notice sent to the affected
individuals.

208.997. 1. The MO HealthNet division shall develop and implement the "Health
Care Homes Program" as a provider-directed care coordination program for MO
HealthNet recipients who are not enrolled in a prepaid MO HealthNet benefits option and
who are receiving services on a fee-for-service basis. The health care homes program shall
provide payment to primary care clinics for care coordination for individuals who are
deemed medically frail. Clinics shall meet certain criteria, including but not limited to the
following:

(1) The capacity to develop care plans;

(2) A dedicated care coordinator;

(3) An adequate number of clients, evaluation mechanisms, and quality
improvement processes to qualify for reimbursement; and

(4) The capability to maintain and use a disease registry.

2. For purposes of this section, "primary care clinic" means a medical clinic
designated as the patient's first point of contact for medical care, available twenty-four
hours a day, seven days a week, that provides or arranges the patient's comprehensive
health care needs and provides overall integration, coordination, and continuity over time
and referrals for specialty care. A primary care clinic shall include a community health
care center.

3. The health care home for recipients of MO HealthNet services defined in
paragraph (f) of subdivision (7) of subsection 1 of section 208.995 shall be the primary
provider of home- and community-based services received by the recipient if such provider
has a qualified, licensed designee to serve as the recipient’s care coordinator and the
provider can demonstrate the ability to meet the requirements in subsections 1 and 2 of this
section. The qualifications for such designees shall be defined by the department by rule.

4. Providers of behavioral, social, and psychophysiological services for the
prevention, treatment, or management of physical health problems and screening and brief
intervention shall be reimbursed for utilizing the behavior assessment and intervention,
and screening and brief intervention reimbursement codes 96150 to 96155 and 99408 to
99409 or their successor codes under the Current Procedural Terminology (CPT) coding
system. Location of service may be limited to NCQA Level 3 Patient-Centered Medical
Homes and CARF-accredited health homes.

5. The department may designate that the health care homes program be
administered through an organization with a statewide primary care presence, experience
with Medicaid population health management, and an established health homes outcomes
monitoring and improvement system.

6. This section shall be implemented in such a way that it does not conflict with
federal requirements for health care home participation by MO HealthNet participants.

7. The department or appropriate divisions of the department may promulgate
rules to implement the provisions of this section. Any rule or portion of a rule, as that term
is defined in section 536.010, that is created under the authority delegated in this section
shall become effective only if it complies with and is subject to all of the provisions of
chapter 536 and, if applicable, section 536.028. This section and chapter 536 are
nonseverable and if any of the powers vested with the general assembly pursuant to
chapter 536 to review, to delay the effective date, or to disapprove and annul a rule are
subsequently held unconstitutional, then the grant of rulemaking authority and any rule
proposed or adopted after August 28, 2013, shall be invalid and void.

8. Nothing in this section shall be construed to limit the department’s ability to
create health care homes for participants in a managed care plan.

208.998. 1. Except for individuals who meet the definition of medically frail,
individuals who qualify for coverage under subsections 2 and 3 of section 208.995 shall
receive covered services through health plans offered by managed care entities which are
authorized by the department. Health plans authorized by the department:

(1) Shall resemble commercially available health plans while complying with
federal Medicaid requirements as authorized by federal law or through a federal waiver,
and may include accountable care organizations, administrative service organizations, or
managed care organizations paid on a capitated basis;

(2) Shall promote, to the greatest extent possible, the opportunity for children and
their parents to be covered under the same plan;

(3) Shall offer plans statewide;

(4) Shall include cost sharing for outpatient services to the maximum extent allowed
by federal law;

(5) May include other co-payments and provide incentives that encourage and
reward the prudent use of the health benefit provided;

(6) Shall encourage access to care through provider rates that include pay-for-performance and are comparable to commercial rates;

(7) Shall provide incentives, including shared risk and savings, to health plans and
providers to encourage cost-effective delivery of care;

(8) May provide multiple plan options and reward participants for choosing a low-cost plan; and

(9) Shall include the services of health providers as defined in 42 U.S.C. Section
1396d(l)(1) and (2) and meet the payment requirements for such health providers as
provided in 42 U.S.C. Sections 1396a(a)(15) and 1396a(bb).

2. The department may designate that certain health care services be excluded from
such health plans if it is determined cost effective by the department.

3. (1) The department may accept regional plan proposals as an additional option
for beneficiaries. Such proposals may be submitted by accountable care organizations or
other organizations and entities.

(2) The department shall advance the development of systems of care for medically
complex children who are recipients of MO HealthNet benefits by accepting cost-effective
regional proposals from and contracting with appropriate pediatric care networks,
pediatric centers for excellence, and medical homes for children to provide MO HealthNet
benefits when the department determines it is cost effective to do so. Such entities shall be
treated as accountable care organizations.

(3) The provisions of subsection 1 of this section shall not apply to this subsection.

4. The department shall establish, in collaboration with plans and providers,
uniform utilization review protocols to be used by all authorized health plans.

(1) The department shall solicit bids only from bidders who offer, or through an
associated company offer, an identical or substantially similar plan, in services provided
and network, within a health care exchange in this state, whether federally facilitated, state
based, or operated on a partnership basis. The bidder, if the bidder offers an identical or
similar plan, in services provided or network, or the bidder and the associated company,
if the bidder has formed a partnership for purposes of its bid, shall include a process in its
bid by which MO HealthNet recipients who choose its plan will be automatically enrolled
in the corresponding plan offered within the health care exchange if the recipient’s income
increases resulting in the recipient’s ineligibility for MO HealthNet benefits. The bidder
also shall include in its bid a process by which an individual enrolled in an identical or
substantially similar plan, in services provided or network, within a health care exchange
in this state, whether federally facilitated, state based, or operated on a partnership basis
whose income decreases resulting in eligibility for MO HealthNet benefits shall be enrolled
in MO HealthNet after an application is received and the participant is determined eligible
for MO HealthNet benefits.

(2) The department shall select a minimum of three winning bids and may select
up to a maximum number of bids equal to the quotient derived from dividing the total
number of participants anticipated by the department in a region by one hundred
thousand.

(3) The department shall accept the lowest conforming bid. For determining other
accepted bids, the department shall consider the following factors:

(a) The cost to Missouri taxpayers;

(b) The extent of the network of health care providers offering services within the
bidder’s plan;

(c) Additional services offered to recipients under the bidder’s plan;

(d) The bidder’s history of providing managed care plans for similar populations
in Missouri or other states;

(e) Any other criteria the department deems relevant to ensuring MO HealthNet
benefits are provided to recipients in such manner as to save taxpayer money and improve
health outcomes of recipients.

6. Any managed care organization that enters into a contract with the state to
provide managed care plans shall be required to fulfill the terms of the contract and
provide such plans for at least twelve months, or longer if the contract so provides. The
state shall not increase the reimbursement rate provided to the managed care organization
during the contract period above the rate included in the contract. If the managed care
organization breaches the contract, the state shall be entitled to bring an action against the
managed care organization for any remedy allowed by law or equity and shall also recover
any and all damages provided by law, including liquidated damages in an amount
determined by the department during the bidding process. Nothing in this subsection shall
be construed to preclude the department or the state of Missouri from terminating the
contract as specified in the terms of the contract, including for breach of contract, lack of
appropriated funds, or exercising any remedies for breach as may be provided in the
contract.

7. (1) Participants enrolling in managed care plans under this section shall have
the ability to choose their plan. In the enrollment process, participants shall be provided
a list of all plans available ranked by the relative actuarial value of each plan. Each
participant shall be informed in the enrollment process that he or she will be eligible to
receive a portion of the amount saved by Missouri taxpayers if he or she chooses a lower
cost plan offered in his or her region. The portion received by a participant shall be
determined by the department according to the department’s best judgment as to the
portion which will bring the maximum savings to Missouri taxpayers.

(2) If a participant fails or refuses to choose a plan as set forth in subdivision (1)
of this subsection, the department shall determine rules for auto-assignment, which shall
include incentives for low-cost bids and improved health outcomes as determined by the
department.

8. This section shall not be construed to require the department to terminate any
existing managed care contract or to extend any managed care contract.

9. All MO HealthNet plans under this section shall provide coverage for the
following services unless they are specifically excluded under subsection 2 of this section
and instead are provided by an administrative services organization:

10. No MO HealthNet plan or program shall provide coverage for an abortion
unless a physician certifies in writing to the MO HealthNet agency that, in the physician's
professional judgment, the life of the mother would be endangered if the fetus were carried
to term.

11. The MO HealthNet program shall provide a high deductible health plan option
for uninsured adults nineteen years of age or older and under sixty-five years of age with
incomes of less than one hundred percent of the federal poverty level. The high deductible
health plan shall include:

(1) After meeting a one thousand dollar deductible, coverage for benefits as
specified by rule of the department;

(2) An account, funded by the department, of at least one thousand dollars per
adult to pay medical costs for the initial deductible funded by the department;

(3) Preventive care, as defined by the department by rule, that is not subject to the
deductible and does not require a payment of moneys from the account described in
subdivision (2) of this subsection;

(6) As soon as practicable, the establishment and maintenance of a record-keeping
system for each health care visit or service received by recipients under this subsection.
The plan shall require that the recipient's prepaid card number be entered, or electronic
strip be swiped, by the health care provider for purposes of maintaining a record of every
health care visit or service received by the recipient from such provider, regardless of any
balance on the recipient's card. Such information shall include only the date, provider
name, and general description of the visit or service provided. The plan shall maintain a
complete history of all health care visits and services for which the recipient's prepaid card
is entered or swiped in accordance with this subdivision. If required under the federal
Health Insurance Portability and Accountability Act (HIPAA) or other relevant state or
federal law or regulation, a recipient shall, as a condition of participation in the prepaid
card incentive, be required to provide a written waiver for disclosure of any information
required under this subdivision;

(7) The determination of a proportion of the amount left in a participant’s account
described in subdivision (2) of this subsection which shall be paid to the participant for
saving taxpayer money. The amount and method of payment shall be determined by the
department; and

(8) The determination of a proportion of a participant’s account described in
subdivision (2) of this subsection which shall be used to subsidize premiums to facilitate a
participant’s transition from health coverage under MO HealthNet to private health
insurance based on cost-effective principles determined by the department.

12. All participants with chronic conditions, as specified by the department, shall
be included in an incentive program for MO HealthNet recipients who obtain specified
primary care and preventive services, and who participate or refrain from participation
in specified activities to improve the overall health of the recipient. Recipients who
complete the requirements of the program shall be eligible to receive an annual cash
payment for successful completion of the program. The department shall establish, by
rule, the specific primary care and preventive services, activities to be included in the
incentive program, and the amount of any annual cash payments to recipients.

13. A MO HealthNet recipient shall be eligible for participation in only one of
either the high deductible health plan under subsection 11 of this section or the incentive
program under subsection 12 of this section.

14. No cash payments, incentives, or credits paid to or on behalf of a MO HealthNet
participant under a program established by the department under this section shall be
deemed to be income to the participant in any means-tested benefit program unless
otherwise specifically required by law or rule of the department.

15. Managed care entities shall inform participants who choose the high deductible
health plan under subsection 11 of this section that the participant may lose his or her
incentive payment under subdivision (7) of subsection 11 of this section if the participant
utilizes visits to the emergency department for non-emergent purposes. Such information
shall be included on every electronic and paper correspondence between the managed care
plan and the participant.

16. The department shall seek all necessary waivers and state plan amendments
from the federal Department of Health and Human Services necessary to implement the
provisions of this section. The provisions of this section shall not be implemented unless
such waivers and state plan amendments are approved. If this section is approved in part
by the federal government, the department is authorized to proceed on those sections for
which approval has been granted; except that, any increase in eligibility shall be contingent
upon the receipt of all necessary waivers and state plan amendments. The provisions of
this section shall not be implemented until eligibility of persons set out in subsection 3 of
section 208.995 has been approved by the federal Department of Health and Human
Services and has been implemented by the department. However, nothing shall prevent
the department from expanding managed care for populations under other granted
authority.

17. The department may promulgate rules to implement the provisions of this
section. Any rule or portion of a rule, as the term is defined in section 536.010, that is
created under the authority delegated in this section shall become effective only if it
complies with and is subject to all of the provisions of chapter 536 and, if applicable,
section 536.028. This section and chapter 536 are nonseverable and if any of the powers
vested with the general assembly pursuant to chapter 536 to review, to delay the effective
date or to disapprove and annul a rule are subsequently held unconstitutional, then the
grant of rulemaking authority and any rule proposed or adopted after August 28, 2013,
shall be invalid and void.

208.999. Subject to appropriations, the department shall develop incentive
programs to encourage the construction and operation of urgent care clinics which operate
outside normal business hours and are in or adjoining emergency room facilities which
receive a high proportion of patients who are participating in MO HealthNet, to the extent
that the incentives are eligible for federal matching funds.

376.961. 1. There is hereby created a nonprofit entity to be known as the "Missouri
Health Insurance Pool". All insurers issuing health insurance in this state and insurance
arrangements providing health plan benefits in this state shall be members of the pool.

2. Beginning January 1, 2007, the board of directors shall consist of the director of the
department of insurance, financial institutions and professional registration or the director's
designee, and eight members appointed by the director. Of the initial eight members appointed,
three shall serve a three-year term, three shall serve a two-year term, and two shall serve a
one-year term. All subsequent appointments to the board shall be for three-year terms. Members
of the board shall have a background and experience in health insurance plans or health
maintenance organization plans, in health care finance, or as a health care provider or a member
of the general public; except that, the director shall not be required to appoint members from
each of the categories listed. The director may reappoint members of the board. The director
shall fill vacancies on the board in the same manner as appointments are made at the expiration
of a member's term and may remove any member of the board for neglect of duty, misfeasance,
malfeasance, or nonfeasance in office.

3. Beginning August 28, 2007, the board of directors shall consist of fourteen members.
The board shall consist of the director and the eight members described in subsection 2 of this
section and shall consist of the following additional five members:

(1) One member from a hospital located in Missouri, appointed by the governor, with
the advice and consent of the senate;

(2) Two members of the senate, with one member from the majority party appointed by
the president pro tem of the senate and one member of the minority party appointed by the
president pro tem of the senate with the concurrence of the minority floor leader of the senate;
and

(3) Two members of the house of representatives, with one member from the majority
party appointed by the speaker of the house of representatives and one member of the minority
party appointed by the speaker of the house of representatives with the concurrence of the
minority floor leader of the house of representatives.

4. The members appointed under subsection 3 of this section shall serve in an ex officio
capacity. The terms of the members of the board of directors appointed under subsection 3 of
this section shall expire on December 31, 2009. On such date, the membership of the board shall
revert back to nine members as provided for in subsection 2 of this section.

5. Beginning on August 28, 2013, the board of directors on behalf of the pool, the
executive director, and any other employees of the pool shall have the authority to provide
assistance or resources to any department, agency, public official, employee, or agent of the
federal government for the specific purpose of transitioning individuals enrolled in the pool
to coverage outside of the pool beginning on or before January 1, 2014. Such authority
does not extend to authorizing the pool to implement, establish, create, administer, or
otherwise operate a state-based exchange.

376.962. 1. The board of directors on behalf of the pool shall submit to the director a
plan of operation for the pool and any amendments thereto necessary or suitable to assure the
fair, reasonable and equitable administration of the pool. After notice and hearing, the director
shall approve the plan of operation, provided it is determined to be suitable to assure the fair,
reasonable and equitable administration of the pool, and it provides for the sharing of pool gains
or losses on an equitable proportionate basis. The plan of operation shall become effective upon
approval in writing by the director consistent with the date on which the coverage under sections
376.960 to 376.989 becomes available. If the pool fails to submit a suitable plan of operation
within one hundred eighty days after the appointment of the board of directors, or at any time
thereafter fails to submit suitable amendments to the plan, the director shall, after notice and
hearing, adopt and promulgate such reasonable rules as are necessary or advisable to effectuate
the provisions of this section. Such rules shall continue in force until modified by the director
or superseded by a plan submitted by the pool and approved by the director.

2. In its plan, the board of directors of the pool shall:

(1) Establish procedures for the handling and accounting of assets and moneys of the
pool;

(2) Select an administering insurer or third-party administrator in accordance with
section 376.968;

(3) Establish procedures for filling vacancies on the board of directors; and

(4) Establish procedures for the collection of assessments from all members to provide
for claims paid under the plan and for administrative expenses incurred or estimated to be
incurred during the period for which the assessment is made. The level of payments shall be
established by the board pursuant to the provisions of section 376.973. Assessment shall occur
at the end of each calendar year and shall be due and payable within thirty days of receipt of the
assessment notice[;

(5) Develop and implement a program to publicize the existence of the plan, the
eligibility requirements, and procedures for enrollment, and to maintain public awareness of the
plan].

3. On or before September 1, 2013, the board shall submit such amendments to the
plan of operation as are necessary or suitable to ensure a reasonable transition period to
allow for the termination of issuance of policies by the pool.

4. The amendments to the plan of operation submitted by the board shall include
all of the requirements outlined in subsection 2 of this section and shall address the
transition of individuals covered under the pool to alternative health insurance coverage
as it is available after January 1, 2014. The plan of operation shall also address procedures
for finalizing the financial matters of the pool, including assessments, claims expenses, and
other matters identified in subsection 2 of this section.

5. The director shall review the plan of operation submitted under subsection 3 of
this section and shall promulgate rules to effectuate the transitional plan of operation.
Such rule shall be effective no later than October 1, 2013. Any rule or portion of a rule,
as that term is defined in section 536.010, that is created under the authority delegated in
this section shall become effective only if it complies with and is subject to all of the
provisions of chapter 536 and, if applicable, section 536.028. This section and chapter 536
are nonseverable and if any of the powers vested with the general assembly pursuant to
chapter 536 to review, to delay the effective date, or to disapprove and annul a rule are
subsequently held unconstitutional, then the grant of rulemaking authority and any rule
proposed or adopted after August 28, 2013, shall be invalid and void.

376.964. The board of directors and administering insurers of the pool shall have the
general powers and authority granted under the laws of this state to insurance companies licensed
to transact health insurance as defined in section 376.960, and, in addition thereto, the specific
authority to:

(1) Enter into contracts as are necessary or proper to carry out the provisions and
purposes of sections 376.960 to 376.989, including the authority, with the approval of the
director, to enter into contracts with similar pools of other states for the joint performance of
common administrative functions, or with persons or other organizations for the performance
of administrative functions;

(2) Sue or be sued, including taking any legal actions necessary or proper for recovery
of any assessments for, on behalf of, or against pool members;

(3) Take such legal actions as necessary to avoid the payment of improper claims against
the pool or the coverage provided by or through the pool;

(4) Establish appropriate rates, rate schedules, rate adjustments, expense allowances,
agents' referral fees, claim reserve formulas and any other actuarial function appropriate to the
operation of the pool. Rates shall not be unreasonable in relation to the coverage provided, the
risk experience and expenses of providing the coverage. Rates and rate schedules may be
adjusted for appropriate risk factors such as age and area variation in claim costs and shall take
into consideration appropriate risk factors in accordance with established actuarial and
underwriting practices;

(5) Assess members of the pool in accordance with the provisions of this section, and
to make advance interim assessments as may be reasonable and necessary for the organizational
and interim operating expenses. Any such interim assessments are to be credited as offsets
against any regular assessments due following the close of the fiscal year;

(6) Prior to January 1, 2014, issue policies of insurance in accordance with the
requirements of sections 376.960 to 376.989. In no event shall new policies of insurance be
issued on or after January 1, 2014;

(7) Appoint, from among members, appropriate legal, actuarial and other committees as
necessary to provide technical assistance in the operation of the pool, policy or other contract
design, and any other function within the authority of the pool;

(8) Establish rules, conditions and procedures for reinsuring risks of pool members
desiring to issue pool plan coverages in their own name. Such reinsurance facility shall not
subject the pool to any of the capital or surplus requirements, if any, otherwise applicable to
reinsurers;

(9) Negotiate rates of reimbursement with health care providers on behalf of the
association and its members;

(10) Administer separate accounts to separate federally defined eligible individuals and
trade act eligible individuals who qualify for plan coverage from the other eligible individuals
entitled to pool coverage and apportion the costs of administration among such separate
accounts.

376.966. 1. No employee shall involuntarily lose his or her group coverage by decision
of his or her employer on the grounds that such employee may subsequently enroll in the pool.
The department shall have authority to promulgate rules and regulations to enforce this
subsection.

2. Prior to January 1, 2014, the following individual persons shall be eligible for
coverage under the pool if they are and continue to be residents of this state:

(1) An individual person who provides evidence of the following:

(a) A notice of rejection or refusal to issue substantially similar health insurance for
health reasons by at least two insurers; or

(b) A refusal by an insurer to issue health insurance except at a rate exceeding the plan
rate for substantially similar health insurance;

(2) A federally defined eligible individual who has not experienced a significant break
in coverage;

(3) A trade act eligible individual;

(4) Each resident dependent of a person who is eligible for plan coverage;

(5) Any person, regardless of age, that can be claimed as a dependent of a trade act
eligible individual on such trade act eligible individual's tax filing;

(6) Any person whose health insurance coverage is involuntarily terminated for any
reason other than nonpayment of premium or fraud, and who is not otherwise ineligible under
subdivision (4) of subsection 3 of this section. If application for pool coverage is made not later
than sixty-three days after the involuntary termination, the effective date of the coverage shall
be the date of termination of the previous coverage;

(7) Any person whose premiums for health insurance coverage have increased above the
rate established by the board under paragraph (a) of subdivision (1) of subsection 3 of this
section;

(8) Any person currently insured who would have qualified as a federally defined eligible
individual or a trade act eligible individual between the effective date of the federal Health
Insurance Portability and Accountability Act of 1996, Public Law 104-191 and the effective date
of this act.

3. The following individual persons shall not be eligible for coverage under the pool:

(1) Persons who have, on the date of issue of coverage by the pool, or obtain coverage
under health insurance or an insurance arrangement substantially similar to or more
comprehensive than a plan policy, or would be eligible to have coverage if the person elected to
obtain it, except that:

(a) This exclusion shall not apply to a person who has such coverage but whose
premiums have increased to one hundred fifty percent to two hundred percent of rates established
by the board as applicable for individual standard risks;

(b) A person may maintain other coverage for the period of time the person is satisfying
any preexisting condition waiting period under a pool policy; and

(c) A person may maintain plan coverage for the period of time the person is satisfying
a preexisting condition waiting period under another health insurance policy intended to replace
the pool policy;

(2) Any person who is at the time of pool application receiving health care benefits under
section 208.151;

(3) Any person having terminated coverage in the pool unless twelve months have
elapsed since such termination, unless such person is a federally defined eligible individual;

(4) Any person on whose behalf the pool has paid out one million dollars in benefits;

(5) Inmates or residents of public institutions, unless such person is a federally defined
eligible individual, and persons eligible for public programs;

(6) Any person whose medical condition which precludes other insurance coverage is
directly due to alcohol or drug abuse or self-inflicted injury, unless such person is a federally
defined eligible individual or a trade act eligible individual;

(7) Any person who is eligible for Medicare coverage.

4. Any person who ceases to meet the eligibility requirements of this section may be
terminated at the end of such person's policy period.

5. If an insurer issues one or more of the following or takes any other action based
wholly or partially on medical underwriting considerations which is likely to render any person
eligible for pool coverage, the insurer shall notify all persons affected of the existence of the
pool, as well as the eligibility requirements and methods of applying for pool coverage:

(1) A notice of rejection or cancellation of coverage;

(2) A notice of reduction or limitation of coverage, including restrictive riders, if the
effect of the reduction or limitation is to substantially reduce coverage compared to the coverage
available to a person considered a standard risk for the type of coverage provided by the plan.

6. Coverage under the pool shall expire on January 1, 2014.

376.968. The board shall select an insurer [or], insurers, or third-party administrators
through a competitive bidding process to administer the pool. The board shall evaluate bids
submitted based on criteria established by the board which shall include:

(4) The insurer's ability to administer the pool in a cost-efficient manner.

376.970. 1. The administering insurer shall serve for a period of three years subject to
removal for cause. At least one year prior to the expiration of each three-year period of service
by an administering insurer, the board shall invite all insurers, including the current
administering insurer, to submit bids to serve as the administering insurer for the succeeding
three-year period. Selection of the administering insurer for the succeeding period shall be made
at least six months prior to the end of the current three-year period.

2. The administering insurer shall:

(1) Perform all eligibility and administrative claim-payment functions relating to the
pool;

(2) Establish a premium billing procedure for collection of premium from insured
persons. Billings shall be made on a period basis as determined by the board;

(3) Perform all necessary functions to assure timely payment of benefits to covered
persons under the pool including:

(a) Making available information relating to the proper manner of submitting a claim for
benefits to the pool and distributing forms upon which submission shall be made;

(b) Evaluating the eligibility of each claim for payment by the pool;

(4) Submit regular reports to the board regarding the operation of the pool. The
frequency, content and form of the report shall be determined by the board;

(5) Following the close of each calendar year, determine net written and earned
premiums, the expense of administration, and the paid and incurred losses for the year and report
this information to the board and the department on a form prescribed by the director;

(6) Be paid as provided in the plan of operation for its expenses incurred in the
performance of its services.

3. On or before September 1, 2013, the board shall invite all insurers and third-party administrators, including the current administering insurer, to submit bids to serve
as the administering insurer or third-party administrator for the pool. Selection of the
administering insurer or third-party administrator shall be made prior to January 1, 2014.

(1) Submit to the board and director a detailed plan outlining the winding down
of operations of the pool. The plan shall be submitted no later than January 31, 2014, and
shall be updated quarterly thereafter;

(2) Perform all administrative claim-payment functions relating to the pool;

(3) Perform all necessary functions to assure timely payment of benefits to covered
persons under the pool including:

(a) Making available information relating to the proper manner of submitting a
claim for benefits to the pool and distributing forms upon which submission shall be made;
and

(b) Evaluating the eligibility of each claim for payment by the pool;

(4) Submit regular reports to the board regarding the operation of the pool. The
frequency, content and form of the report shall be determined by the board;

(5) Following the close of each calendar year, determine the expense of
administration, and the paid and incurred losses for the year, and report such information
to the board and department on a form prescribed by the director; and

(6) Be paid as provided in the plan of operation for its expenses incurred in the
performance of its services.

376.973. 1. Following the close of each fiscal year, the pool administrator shall
determine the net premiums (premiums less administrative expense allowances), the pool
expenses of administration and the incurred losses for the year, taking into account investment
income and other appropriate gains and losses. Health insurance premiums and benefits paid by
an insurance arrangement that are less than an amount determined by the board to justify the cost
of collection shall not be considered for purposes of determining assessments. The total cost of
pool operation shall be the amount by which all program expenses, including pool expenses of
administration, incurred losses for the year, and other appropriate losses exceeds all program
revenues, including net premiums, investment income, and other appropriate gains.

2. Each insurer's assessment shall be determined by multiplying the total cost of pool
operation by a fraction, the numerator of which equals that insurer's premium and subscriber
contract charges for health insurance written in the state during the preceding calendar year and
the denominator of which equals the total of all premiums, subscriber contract charges written
in the state and one hundred ten percent of all claims paid by insurance arrangements in the state
during the preceding calendar year; provided, however, that the assessment for each health
maintenance organization shall be determined through the application of an equitable formula
based upon the value of services provided in the preceding calendar year.

3. Each insurance arrangement's assessment shall be determined by multiplying the total
cost of pool operation calculated under subsection 1 of this section by a fraction, the numerator
of which equals one hundred ten percent of the benefits paid by that insurance arrangement on
behalf of insureds in this state during the preceding calendar year and the denominator of which
equals the total of all premiums, subscriber contract charges and one hundred ten percent of all
benefits paid by insurance arrangements made on behalf of insureds in this state during the
preceding calendar year. Insurance arrangements shall report to the board claims payments made
in this state on an annual basis on a form prescribed by the director.

4. If assessments exceed actual losses and administrative expenses of the pool, the excess
shall be held at interest and used by the board to offset future losses or to reduce pool premiums.
As used in this subsection, "future losses" include reserves for incurred but not paid claims.

5. Assessments shall continue until such time as the director of the pool provides
notice to the board and director that all claims have been paid.

6. Any assessment funds remaining at the time the director provides notice that all
claims have been paid shall be deposited in the state general revenue fund.

Section 1. 1. Notwithstanding any other provision of law to the contrary, beginning
July 1, 2014, any MO HealthNet recipient who elects to receive medical coverage through
a private health insurance plan instead of through the MO HealthNet program shall be
eligible for a private insurance premium subsidy to assist the recipient in paying the costs
of such private insurance if it is determined to be cost effective by the department. The
subsidy shall be provided on a sliding scale based on income, with a graduated reduction
in subsidy over a period of time not to exceed two years.

2. The department may promulgate rules to implement the provisions of this
section. Any rule or portion of a rule, as that term is defined in section 536.010, that is
created under the authority delegated in this section shall become effective only if it
complies with and is subject to all of the provisions of chapter 536 and, if applicable,
section 536.028. This section and chapter 536 are nonseverable and if any of the powers
vested with the general assembly pursuant to chapter 536 to review, to delay the effective
date, or to disapprove and annul a rule are subsequently held unconstitutional, then the
grant of rulemaking authority and any rule proposed or adopted after August 28, 2013,
shall be invalid and void.

Section 2. 1. There is hereby established in the department of social services the
“MO HealthNet Transformation Task Force”, which shall consist of sixteen members as
follows:

(1) The director of the department of social services, or his or her designee;

(2) The director of the department of health and senior services, or his or her
designee;

(3) The director of the department of mental health, or his or her designee;

(4) Four members of the house of representatives, including two from each political
party;

(5) Four members of the senate, including two from each political party; and

(6) Five members from the Missouri health care community who shall be appointed
by the governor with senate approval.

2. The task force shall make recommendations in a report to the general assembly
on improvements that can be made to the state medical assistance health care delivery
system. The report shall include, but not be limited to, the following:

(1) Advice on more efficient and cost-effective ways to provide coverage for MO
HealthNet participants;

(2) An evaluation of how coverage for MO HealthNet participants can resemble
that of commercially available health plans while complying with federal Medicaid
requirements;

(3) Possibilities for promoting healthy behavior by encouraging patients to take
ownership of their health care and seek early preventative care;

(4) Advice on the best manner in which to provide incentives, including a shared
risk and savings to health plans and providers to encourage cost-effective delivery of care;
and

(5) Ways that individuals who currently receive medical care coverage through the
MO HealthNet program can transition to obtaining their health coverage through the
private sector.

3. The task force shall meet at least quarterly and shall submit its recommendations
and statewide plan for improvements to the MO HealthNet plan to the governor, the
general assembly, and the director of the department of social services by December thirty-first of each year.

4. Members of the task force shall receive no additional compensation, but shall be
eligible for reimbursement for expenses directly related to the performance of task force
duties.